Drugging unhappiness: Canadians now among world’s biggest consumers of antidepressants

One of Canada’s top psychiatrists says too many Canadians are treating life’s normal spells of misery the way they would handle something they dislike about their bodies: By asking a doctor to make their lives better.

That may explain why we take twice as many antidepressants as Italians do, and more than Germans or French, says Dr. Joel Paris, professor and past chair of the department of psychiatry at Montreal’s McGill University.

“We’re not always happy, and there are often good reasons for unhappiness,” Paris says. “But there’s this idea that we should all have high self-esteem, fantastic relationships and tremendous jobs.

“It’s like cosmetic psychopharmacology: If you don’t like the way you look, you go to a plastic surgeon and get it fixed. If you’re not happy enough, go to a doctor and go on antidepressants.”

Canadians now rank among the highest users of antidepressants in the world: in 2011, the last year for which comparative figures are available, Canada reported the third highest level of consumption of antidepressants among 23 member nations surveyed by the Organization for Economic Co-operation and Development.

The OECD figures, contained in its recently released “Health at a Glance” report, shows Canadians consumed 86 daily doses of antidepressants for every 1,000 people per day in 2011, more than the United Kingdom (71 doses per day), Spain (64) and Norway (58). Canada was behind only Iceland (106 doses per 1,000 people per day) and Australia (89 doses) among the countries surveyed.

(The data are expressed as “defined daily doses,” which means the average daily maintenance dose for the condition for which the drug was prescribed.)

In Canada 42.6 million prescriptions for antidepressants were filled by retail drugstores in 2012, up from 32.2 million in 2008, according to figures provided to Postmedia News by prescription-drug tracking firm IMS Brogan. Citalopram (sold under the brand name Celexa), venlafaxine, (Effexor) and the generic drug, trazodone, make up the three top-selling antidepressants in Canada.

Paris and others stress that antidepressants are essential in cases of severe, debilitating and life-threatening depression.

But the pills, including Prozac and its cousins that were held out to be miraculous when they hit the market in the late 1980s, are being swallowed by millions of Canadians every day, even while studies suggest that, in cases of mild depression, where “you’re still working, you’re still functioning,” Paris says, the drugs often don’t work, or they produce a temporary placebo effect, which doesn’t last.

“And then you get onto this thing, where you try another one, and you try a third one, and then you add some other type of drug entirely,” Paris says. “It’s a whole treadmill of pharmacology people get caught up in,” he said. Once people start taking the drugs, they’re often terrified to stop. “The fear of relapse has driven doctors to keep people on them for years,” Paris says.

The pills aren’t innocuous: Drug companies were ordered a decade ago to add a warning of increased risk of suicidal thinking and behaviour to the blockbuster class of antidepressants known as SSRIs, or selective serotonin reuptake inhibitors. The pills can also cause more subtle problems, such as a decrease in sexual interest or desire, and they can be difficult to come off.

But, overall, they’re generally well tolerated, Paris says. Some people now stay on them for years. “Part of the problem is that they’re not toxic enough to make people want to stop them.”

According to Paris and other experts, the main factors driving the nearly $1.8 billion anti-depressant drug market in Canada include that family doctors — who do the bulk of the prescribing, and often with little formal training in their use — are ordering antidepressants more freely, patients are asking for them and psychotherapy is expensive and not widely accessible.

It’s also too easy to get a diagnosis, they say.

The diagnostic criteria for “major depressive disorder” are so flexible and rubbery, observers say, half the population will meet the criteria at some point in their life. “At least half, maybe more,” Paris says. “It’s almost like the common cold.”

For example, according to the Diagnostic and Statistical Manual of Mental Disorders, or DSM, psychiatry’s official guidebook of mental sickness now in its fifth edition, people can meet the criteria for major depressive disorder if they experience two weeks’ worth of a depressed mood most of the day, loss of interest, changes in appetite, reduced energy and problems sleeping.

But those symptoms can follow a breakup, a job loss or many of the normal sorrows and grief of every day life, says Dr. Allen Frances. According to the renowned U.S. psychiatrist, “over-diagnosis of depression is now more common than under-diagnosis.”

In a recently published article in the British Medical Journal titled “Medicalizing unhappiness,” Frances, former chair of the department of psychiatry at Duke University and author of Saving Normal, and co-author Christopher Dowrick blame the rush for antidepressants on a “trend in Western societies to expect the right to happiness.”

Too many people, adds Frances, who chaired the task force that wrote the fourth edition of the DSM, believe the messages in the drug ads, that all depression is a brain disease, “that people who are sad are depressed — clinically depressed — that depression is easy to diagnose, that it’s due to a chemical imbalance in the brain and that the solution is a pill.”

“The best patient for drug companies is someone who is basically healthy. Because they get the best results, and they’re the most loyal customers,” says Frances.

“Meanwhile, we’re shamefully neglecting the people who really need help.”